People with high level spinal cord injury will often have breathing difficulties. You may benefit from using Bipap (Bi-level positive airway pressure) or CPAP (Continuous Positive Airway Pressure) to assist you with your breathing. Bipap and CPAP are non-invasive ventilatory support therapies. This means they can be used without a tracheostomy.
Bipap and CPAP are provided through a mask that covers the nose or through plugs inserted into the nose. Bipap works by helping inflate the lungs to make breathing less difficult. CPAP helps to keep the airways open when they are prone to collapse. They are therapies used mainly at night while you sleep but can also be used during the day when needed – like when you have a cold and your breathing muscles are working harder. For more information, ask your respirologist or respiratory therapist.
Post acute care
You can access a respirologist or respiratory therapist by referral from your physician.
High lesion spinal cord injury (HLSCI)
Breathing and your injury
If you have had an injury at C3 or higher, your diaphragm muscle will probably no longer get the messages it needs to work and help you breathe. This means you may need help breathing by a breathing machine (ventilator).
Listening to your lungs
When you breathe in, air should travel all the way to the bottom of your lungs. The air can be heard through a stethoscope. When a therapist listens to your lungs and hears different breath sounds in some areas, this means that little or no air is getting to those areas. Those areas may be filled with thickened secretions and therefore no gas exchange happens and the little air sacs flatten.
Also, if there is a mucous plug in any portion of your airway, then no air will get to the areas below the plug. Mucous plugs are common in people with HLSCI. The plugs can make you feel you are not getting enough air and the plugs need to be coughed up or suctioned to clear the airways.
Drinking plenty of fluids can help to thin secretions and make them easier to cough up.
Need for a tracheostomy
If you have had an injury at C1, C2, or C3, you may require the use of a breathing machine (ventilator) either some or all of the time. The ventilator delivers air into your lungs through an attachment called a tracheostomy tube (tra-key-aus-toe-me tube). This tube is attached to your trachea (windpipe) through a hole in your neck. Air is sent from the ventilator, through this tube into your lungs. Secretions can be removed from your lungs by suctioning through the tube.
Generally, there are two kinds of tracheostomy tubes: cuffed and uncuffed.
The cuffed tubes are generally used in acute care and non-cuffed tubes are for long-term use. A cuffed tracheostomy tube has a soft balloon on the end which ensures that you are getting all the air in your lungs that is delivered by the ventilator. However, it does not allow you to speak because air is not allowed to pass through to your vocal cords.
On the other hand, with a non-cuffed tracheostomy tube, air flows around the tube through to the vocal cords and allows you to speak.
Some people in acute care have a tracheostomy with lower injury levels and multitraumas. This may be short-term. People with an injury at C1, C2 or C3 will have a tracheostomy long term.
Difficulties with tracheostomy tubes
A tracheostomy tube can be a good thing as it makes breathing easier, however there can also be problems with it. Having a tracheostomy may increase your chance of getting an infection because the tube is an invasive foreign object. Therefore, it is important that you watch around the hole for drainage and be aware of what colour your secretions are;. they should be clear.
Yellow, green, or brown secretions might mean that you have an infection in your lungs. Also, speaking may be more difficult, especially if you are attached to a breathing machine because you can only speak when you breathe in or inhale. Swallowing may cause some irritation to your tracheostomy site as the skin rubs against the faceplate of the tube. Also a tracheostomy may impair the swallow functioning. When there are increased secretions and these become hard and dry, then the skin at the tracheostomy site may be painful because of the irritation.
Tracheostomy care
You have probably found already that there are many ways to care for your tracheostomy – from a sterile approach in a hospital setting to a clean method in the rehab setting and your home. Tracheostomy tubes need cleaning and changing regularly. If you have the inner tube cleaned once a day, you can have your outer and inner tube changed once a month.
Usually the stoma and the dressing around it need cleaning and changing on a regular basis as well. Perhaps every couple of days will be frequent enough for you, however if you find you have lots of secretions around your stoma you will need to clean it more frequently.
Plastic tracheostomy tubes are disposable. However the inner cannula can be cleaned with ½ hydrogen peroxide, ½ normal saline solution daily.
The gauze and ties may be changed when they are soiled or when your tracheostomy tube gets changed.
Suctioning
Suctioning is needed when you feel or hear secretions in your airway and lungs. If you are attached to a ventilator, the high pressure alarm may go off because the machine needs to work harder to push the air into your lungs when they are full of secretions. While you were in acute care, an inline suctioning procedure was done with a catheter in a sterile sleeve. This means that suction equipment was changed after its use. Sterile gloves may have been used.
At home, a “clean” method works very well. A catheter may be reused after having been soaked in chlorhexidine, thoroughly rinsed in saline solution, dried with gauze or towel, and stored in a clean dry container. You will probably want to have a battery-powered portable suction machine for use when you are away from home.
Remember, it is up to you to teach family members and attendants how to suction you.
Ventilators
If you have had an injury at C3, your diaphragm muscle will probably no longer get the messages it needs to work and help you breathe. This means you may need help breathing by a ventilator.
The most common form of breathing supports for persons with HLSCI are ventilators on which you can set the amount of air that will be pushed into your lungs. This means that a pre-set amount of air is blown into your lungs to expand them.
The ventilator will control how often you breathe and how big your breaths are. This information will be decided by your physician and then set into the ventilator. The ventilator also has built-in alarms to tell if anything is wrong with the system.
Most ventilators will include the following settings:
• Respiratory rate – this is how fast you breathe
• Tidal volume – this is how big a breath you take, or how much air is being delivered to your lungs with each breath
• Assist/control mode – decides if the machine is going to do all the breathing for you or if you will be able to help with some of the breathing
• High pressure alarm –this alarm sounds if the machine has to work harder than normal to push the air into your lungs. For example, if there was a kink in the tubing or lots of secretions in your lungs or you are coughing, the ventilator would have to work harder to force the air into your lungs and it would let you know by alarming.
• Low pressure alarm – this alarm sounds if the machine senses that it is easier than usual to push the air into your lungs. For example, if there is a disconnection in your tubing or a leak in the system, the ventilator would not have to work as hard to get the air into your lungs and it would let you know by alarming.
It is really important for you to know and understand all the controls on your ventilator so you can troubleshoot when necessary. You should have two ventilators in case one breaks down or is in need of repair.
A manual resuscitation bag is another piece of equipment you must have with you at all times. You need the bag in case something goes wrong with your ventilator. A resuscitation bag delivers air into your lungs; this is done by squeezing the bag. The bag usually attaches to the tracheostomy tube.
Many types of bags are available on the market. Again, it is important for you to familiarize yourself, as well as your attendant, with the parts and use of your resuscitation bag.
Weaning
Weaning means that the breathing machine is turned off for a while so you can try to breathe on your own. Weaning you from a ventilator may have already started while you were in acute care. If not, then it may happen in another setting. Being “off” the ventilator for short periods of time may be good for you as it will prevent further weakening of the respiratory muscles you use to breathe. As well, it can help you to breathe a little bit on your own in case there is not an attendant close to you if you become accidentally disconnected from the ventilator. However, you must realize that not all persons with a high lesion spinal cord injury can be weaned from the ventilator
Tests done by the respiratory therapist will help to decide the length of time for the initial wean. Short periods of weaning are preferred initially to help build your confidence, strength and endurance.
A wean can be as short as 15 seconds or as long as 5 to 10 minutes off the ventilator. Generally, this is repeated two times a day if possible. Progress in weaning depends on the level of your injury; the higher the level, the more difficult it may be. The respiratory therapist will continually monitor your initial weaning efforts.
Speech-Language Pathologist and respiration for communication
The Speech-Language Pathologist (SLP) has a variety of roles in the care of spinal cord injury patients. If you are trached and ventilated you have no means of verbal communication because you are unable to use your voice. The SLP works closely with Respiratory Therapy to see if you can talk by assessing whether or not you could use a fenestrated tracheostomy, finger occlusion of tracheostomy, a speaking valve with tracheostomy, or a talking tracheostomy (if you are dependent on a ventilator).
If verbal communication is not possible or effective for you, the SLP will assess you for use of an Alternative or Augmentative Communication (AAC) device. An AAC device may be a simple picture communication board if you require short-term AAC. High technology communication devices are also available if you need long-term alternative means of communication.
If verbal communication is possible, you may find it difficult to speak loudly or say long sentences on a single breath because your diaphragm muscle may not work sufficiently or efficiently. The SLP can help teach you how to compensate for these issues by providing you with a voice amplifier to increase your volume or teaching you how to better coordinate your breathing with turning on your voice. If you have any concerns about communication an SLP should be involved in your care.